MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

A recent article from THE CHIROPRACTIC REPORT entitled ‘Media Criticism – Whether and How to Respond’ has caught my attention. It provides detailed and, in my view, quite remarkable advice to chiropractors as to how they should react to criticism. Here is an excerpt:

…the easiest media comment to challenge is one that makes an absolute claim – for example Salzberg’s claim that the practice of chiropractic is “highly dubious.” It also means that an effective response should usually not be absolute – claiming for example that chiropractic care can cure, or a specific chiropractic treatment is proven effective for, a specific condition.

Let’s explore this with an example. In 2008 a British journalist, Simon Singh, while promoting a new book he had co-authored that was heavily critical of chiropractic and complementary and alternative medicine in general, wrote an article in the Guardian newspaper in which he claimed that “there is not a jot of evidence” that chiropractic treatment can help children with “colic, sleeping and feeding problems . . . and prolonged crying.” In other words, a black and white claim.

There was and is evidence. Singh was wrong. How might you respond to this? Here are your options for reply, from the outspoken to the restrained:

a. Chiropractic is proven effective for the cure of infantile colic.

b. Spinal manipulation is proven effective for the cure of infantile colic

c. Manual treatments are proven effective for the cure of infantile colic

d. Chiropractic/spinal manipulation/ manual therapies may be effective in reducing the symptoms of infantile colic.

e. Where spinal joint dysfunction/subluxation is found, chiropractic/spinal manipulation/manual therapies may be effective in reducing abnormal and incessant crying in infants medically diagnosed as having infantile colic

f. Chiropractic care has a central focus of assessing and correcting spinal joint dysfunction/subluxation and its biomechanical and physiological effects, and where these are addressed many symptoms may be reduced including those associated with infantile colic.

The first three options are as black and white as Singh’s statement, and are not supported by the evidence. Some studies say yes, some no. All the other options, which have appropriate qualifiers and shades of gray, are supported by sound evidence.

Much of that evidence is referred to and referenced in the March 2010 issue of this Report, available online at www.chiropracticreport.com/pastissues. To answer Singh effectively one only has to produce some of the good quality research and question how he can be credible when he says “there is not a jot of evidence”.

With respect to evidence, in this context that means evidence published in peer-reviewed scientific journals. You may decide to comment on one or more anecdotal case reports from your practice to give your response greater human interest, but this will mean nothing unless supported by higher levels of published evidence.

Am I the only one to find this remarkable?

Am I wrong in interpreting this as detailed instructions to mislead the public?

Are these instructions not merely advice to defend chiropractic commercial interests at the expense of public health?

How can this be ethical?

18 Responses to Are chiropractors being taught to mislead the public ?

  • We clearly do not need to re-run the Singh case again here, but note should be taken of exactly what Singh did say in his original article:
    “The British Chiropractic Association claims that their members can help treat children with colic, sleeping and feeding problems, frequent ear infections, asthma and prolonged crying, even though there is not a jot of evidence.”
    This has been misquoted in the article to which this posting refers and which claims Singh said:
    “there is not a jot of evidence that chiropractic treatment can help children with colic, sleeping and feeding problems . . . and prolonged crying.” That is not what Singh said.

    I believe I know what Simon meant, but pressure of space in a newspaper did not allow the exactitude of expression which was needed. It is for Simon to state what he did mean, but there was and is evidence that BCA did and do make claims in respect of children ‘with…problems’.
    Note: neither Simon nor BCA claimed the problems were cured, or even treated – rather Simon referred to ‘helping treat children and the article under discussion refers (misquoting) to ‘help children’.
    In other words – the patient was treated (TLC etc.) but no mention by Singh or the article that chiropractic adjustment has any effect (or does not) on the pathological causes of the problems.
    Indeed, it is axiomatic in paediatrics that treating the parents is (nearly) as important as treating the patient.
    The article’s author acknowledes there is no evidence for his statements a, b, c – and goes with the shify semantics of ‘d’ refering to ‘treating symptoms’.
    Which most certainly is not the same as treating any pathological cause of the symptoms.
    ‘e’ and ‘f’ contain too many ‘may’s to be of any value. Pigs might fly, you never know for sure.
    All this article shows is that chiropractors care. Care is comforting to patients. There is no credible evidence offered that chiropractic adjustments affect any recognisable disease process.
    Further research is needed which separates the practitioner from the practice, the therapist from the therapy, the style from the substance.
    Chiropractors are unlikely to conscientiously do such research as it might show there was nothing to be gained from chiropractic adjustments and therefore, from chiropractic.

  • When it comes to alternative medicine, there seems to be a different set of standards for what constitutes science and ethics. Does this make the standard of care legally acceptable when a practitioner meets the community standard? The low level of litigation seems to suggest that it does. If the patients want this sort of treatment this will be hard to change. I find that most chiropractic patients are not receptive to criticism of their “Doctors”.

    • “…most chiropractic patients are not receptive to criticism of their “Doctors” ”
      Indeed, folks are funny arn’t they.
      The majority of people (either sex) who are subject to domestic abuse (and most other crimes) do not complain.
      Should we just walk by on the other side and ignore the problem?
      Education is indeed hard, but what is the alternative?

  • There is much good advice in that report, especially the Do’s and Don’ts of how to respond to critics. Some chiropractors who come on this blog would benefit from reading them! Cherry picking Edzard!
    https://www.chiropracticreport.com/index.php/past-issues/view_document/72-no-4-media-criticism-whether-and-how-to-respond

    • Thank you for helping us understand how Edzard is cherry picking by linking us to exactly the same full article Edzard already linked to perfectly clearly in differently coloured type in the first sentence of his post.

      The full article, on my reading, is indeed a dissembling, obfuscating, weasel-worded defence of the indefensible. Let me give a single example: low-back pain, the one entity where chiropractors reckon they have a good case. “Since the 1990s national and international evidence-based clinical guidelines have endorsed the chiropractic approach to management by recommending spinal manipulation, NSAIDs, patient education and motivation, and early return to activity as the appropriate first lines of management for patients with acute or chronic mechanical LBP.”

      In support of this statement four references are cited.

      The first is a 1994 HMSO document accessible at http://www.chiro.org/LINKS/GUIDELINES/Acute_Lower_Back_Problems_in_Adults.html — a chiropractic website. Spinal manipulation is recommended in the executive summary, provided it is done within the first month of onset and stopped if no improvement is seen within a month. In the article detail we discover this is based on five recommendations, one with strength of evidence rated B — moderate — and the other four either C or D, where D is ” Panel interpretation of information that did not meet inclusion criteria as research-based evidence.”!

      The second is a two-page editorial in a paid, 1995 supplement to the journal Spine, entirely on the topic of whiplash injuries (and their study in the province of Quebec). The first page of the article cited, which appears to be most of it, is visible behind the paywall. There is no recommendation of spinal manipulation for low-back pain. Indeed, the editorial contrasts work on whiplash favourably with the poor research done on lower-back pain.

      The third citation is to European back pain guidelines. The link is to a website that mainly details the management set-up of three EC working groups on acute and chronic low-back pain and its prevention. No actual guidelines are provided on this website. However, there are four links to putatively relevant publications. The first of these is totally incongruous: a page from a US website that’s headed “The list below identifies guidelines that have been withdrawn from the NGC Web site.” The second links to an article with European guidelines on prevention of lower back pain, which has this to say about spinal manipulation: “No evidence was found to support recommending regular manipulative treatment for the prevention in LBP (level D).” The third link is to a Lancet article that’s a “Clinical update”, not EU guidelines, but which at last at least mentions spinal manipulation as an option: “The current recommendations for patients with acute low back pain include: adequate information and reassurance; advice to stay active and continue normal activities; analgesia, if necessary; and (consideration of) spinal manipulation for patients who are failing to return to normal activities. B”. The fourth link is to guidelines on pelvic girdle pain (not lower-back pain), which recommends the following: “There is no evidence to recommend manipulation or mobilisation for PGP. However, manipulation or joint mobilisation may be used to test for symptomatic relief, but should only be applied for a few treatments.”

      The fourth citation is to guidelines from the American College of Physicians and the American Pain Society. “For patients who do not improve with selfcare options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).”

      So the article under discussion in this thread, in addition to recommendations as to how best chiropracters should dissemble, provides four citations for lower back pain therapy, which either have nothing to do with lower back pain, recommend against spinal manipulation, or support such a recommendation in qualified tones because of the mostly weak evidence available.

      Thinking (sic) Chiro, you repeatedly carpet bomb this blog with lists of citations and were recently called out on this practice by Bjorn Geir. I have occasionally looked at some of the things you cite, but rapidly lose patience as they turn out to be surveys of how chiros like to work, irrelevant studies, opinion pieces and the like. You say, somewhat pompously, that some chiropracters who come on this blog would benefit from reading the Do’s and Don’ts article. I’d further suggest, perhaps equally pompously, that some chiropracters who come on this blog would benefit from learning the fundamentals of academic scholarship.

  • It would seem that we are reading the article from differing perspectives.
    The articles I have cited prevoiusly are from chiro’s, physio’s, medico’s on the treatment of chronic pain and are not irrelevant studies or opinion pieces. If it is multiple surveys on how chiropractors practice and the critics are implying that we are all into subluxation then I would say that they are relevant!
    As for the fundamentals of academic scholarship, I would have to agree with you. I am not a researcher or career academic, who read a paper differently to someone in private practice. I am looking for best practice and latest evidence and how it relates to the way I practice.
    The critics ask for evidence so I will continue to cite the latest research from all relevant professions. I will take the advice given onboard that I reduce the number of citations. Put the previous large numbers down to frustration with the critics!

    • TC persists in maintaining chiropractic should be regarded in some way as a ‘health profession’. (“The critics ask for evidence so I will continue to cite the latest research from all relevant professions.”
      Chiropractic is a faith. (The more so if there is a belief that adjusting a ‘subluxation’ has benefit).
      Get over it and move on.
      No one will ever proove it’s nonsense to the satisfaction of those of faith.
      We must go our separate ways.
      Good luck.

    • @Thinking_Chiro
      I think you’re missing the point. You claimed there is much good advice in the article that is the original post topic of this thread. I read the article and found it full of recommended obfuscations. But it got worse. I looked in detail at the paragraphs about Rx of lower back pain, since that seems to be one of the big areas for chiropractic referral. The article’s suggestions for how chiropractors should respond to critics included the statement that clinical guidelines have endorsed spinal manipulation for treatment of lower back pain. It cited four references in support of this contention. But only three of the citations were to published articles — the fourth was to a website. Of the three, two were 20 years old and one of them wasn’t even about lower back pain. The third, more recent article mentioned spinal manipulation alongside several other therapies (including acupuncture) as a “weak recommendation”. In other words, the article’s claim that clinical guidelines have endorsed spinal manipulation is a porkie pie. And this is the best evidence you see as good advice to chiropractors?!
      The usual (scholarly) way to cite evidence is to make a claim or a statement, and refer to published research articles that support that claim or statement. Professional surveys are not good sources, because their results depend on who is asked and how the questions are posed. A good original research paper sets out clearly the methods used, and the detailed results obtained. The readers may then judge for themselves whether or not they agree with the article’s own conclusions. Review articles are often helpful citations, but the quality of reviews can vary enormously. Websites are dodgy citations, and meeting abstracts are simply not acceptable. Anyone can write anything in a meeting abstract.
      In your previous carpet bomb of citations, the first two articles were studies showing, by means of sensors fixed to vertebrae of patients undergoing surgery, that thrusts applied to one vertebra cause movements in adjacent vertebrae; and that similar thrusts stimulate electrical signals in adjacent nerves and muscles. One suspects that subsequent studies from these authors discovered that the Pope is a Catholic, that bears defaecate in the woods and that Dolly Parton sleeps on her back.

  • PS

    I see my comment on citing evidence looks like an open invitation to cherry picking. I should perhaps have better phrased it this way… The usual (scholarly) way to cite evidence is to make a claim or a statement and refer to all published research articles that support or refute that statement. If you disagree with the non-supportive articles, you then explain why.

  • In reply to Richard Rawlins:
    I never adopted subluxation, I critically assess what I do and as best evidence presents itself I change the way I practice. Subluxation is set in concrete and resistant to change, that is the hallmark of a faith. I moved on 25+ years ago that is the point I have repeatedly made. Additionallly, the majority of the profession has done the same.

    In reply to FrankO:
    Don’t get emotional, don’t attack medicine or other professions, remain calm, weigh the evidence from both sides, be measured and professional not aggressive or rude etc are all good advice! There is many a time I have taken a deep breath and take my time in replying to comments. Some critics can be as deeply entrenched, frustrating and resistant to change as the worse subluxation based true believer! Other critics appreciate and enjoy the debate as much as I do and are prepared to make concessions. Its all part of the reform process so worth the effort! I will continue to work on you and Richard! I enjoy a challenge!

    • What you describe is a conversation, not a proper scientific exchange of views. Anyone can look at any sort of undefined “evidence” and come to all sorts of “conclusions”, but that is not the scientific method in any way. It’s great that you don’t accept, endorse, or practice subluxation theory, and you may be a very nice, concerned and decent person; but that does not mean that chiropractic is effective for anything at all. You may make people “feel better,” but that is a difficult thing to evaluate and does not mean that anything has changed physiologically for them. Some of us feel that if you are going to take people’s money and not do them any harm (even by preventing them seeking proper medical care), you need to demonstrate that what you do actually works beyone the placebo effect.

  • An interesting discussion so far, but it leaves aside the fact that this article as quoted is indeed teaching a sales technique, just as any course for sales personnel would do. The question surely is to what extent this might be right or not – I mean is it right to teach people these techniques or not, not is the argument for chiropractic right in this case.

    Does your GP ‘sell’ you treatments? If he is in the NHS almost certainly not; in the private sector things can be different. Why? Because private profit comes into it.

    • Well, there are doctors who “market” themselves and in NY they offer “concierge” services. All the hospitals have billboards now and drugs are hawked non-stop on TV (I don’t have one, but I do see at friends’, and such). Many dermatologists sell products and I find this questionable, but at least they are not promising amazing cures or making disease claims based on the four humours. All this advertising came about in the 80’s and I think it’s a travesty, but most individual doctors don’t tout theselves beyond the picture and blurb that the hospital or clinic provide in their insurance booklet or on a website. I think, fortunately, ethics still picks up where laws leave off. Institutions, however, market themeselves extensively these days and it’s a travesty that rather shocks people my age (retired). But even so, they market legitimate services, not snake oil and I think that’s the point.

      On a more anecdotal basis, I once had a doctor who got into multi-level marketing and tried to not only sell me stuff (mostly supplements), but tried to recruit me into the scheme as well! I never saw him again. Sadly, there is nothing to stop this that I know of.

  • “It is difficult to get a man to understand something when his salary depends upon his not understanding it.”
    Upton Sinclair (1878-1968)

  • An interesting article in the latest issue of Edzard’s journal, Focus on Alternative and Complementary Therpaies (FACT):

    The face of chiropractic: evidence-based?

    Abstract

    Background
    Chiropractors are the most accessed providers of complementary and alternative medicine care in Canada. However, some scepticism exists around the evidentiary base of the chiropractic profession.

    Objectives
    To examine the messages utilised by the chiropractic profession around issues of scope and efficacy through website communication with the public.

    Methods
    Website content of major Canadian chiropractic associations and colleges (n=11), and commercial clinics (n=80) was submitted to a mixed-methods analysis. Content was reviewed to quantify specific health conditions described as treatable by chiropractic care. A qualitative textual analysis identified the primary messages related to evidence and efficacy utilised by the websites.

    Results
    Website content claimed that chiropractic is capable of addressing a wide range of health issues. Quantitative analysis revealed that association and college websites identified a total of 41 unique conditions treatable by chiropractic, while private clinic websites named 159 distinct conditions. The most commonly cited conditions included back pain, headaches/migraines and neck pain. Qualitative analysis revealed three prominent themes drawn upon in discussions of efficacy and evidence: grounded in science, the conflation of safety and efficacy and “natural” healing.

    Conclusions
    The chiropractic profession claims the capacity to treat health conditions that exceed those more traditionally associated with chiropractic. Website content persistently declared that such claims are supported by research and scientific evidence, and at times blurred the lines between safety and efficacy. The chiropractic profession may be struggling to define themselves both within the paradigm of conventional science as well as an alternative paradigm that embraces natural approaches.

    The full paper can be read here.

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